198602365-11-13-2023-11-AS-RCLD-CXJU4J-20231113141512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602365
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:15:25 PM

Document Has Been Signed on 11/13/2023 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CN HOME 3		FACILITY NUMBER:	198602365
ADMINISTRATOR:	MANBIR SOND		FACILITY TYPE:	735
ADDRESS:	1511 W 219TH STREET		TELEPHONE:	(310) 612-0978
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 4		CENSUS: 4	DATE:	11/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Gloria Callejas		TIME COMPLETED:	02:20 PM

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On 11/13/2023 at around 8:58 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with staff (S1) Gloria Callejas. LPA explained the purpose of the visit and were accompanied by S1 inside and outside the facility during this inspection.

The home consists of 4 client bedrooms, 1 staff office, 3 bathrooms, living room, dining room, laundry room, kitchen, shaded patio and front porch.

This facility is licensed to serve 4 non-ambulatory adults ages 18 – 59 years. A total of 4 clients are currently residing in this facility. A total of 3 staff and 3 clients were present during this inspection.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

4 out of 4 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Cloyd tested hot water temperature and it measured between 111- and 116-degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, and toothpaste.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME 3	FACILITY NUMBER: 198602365
	VISIT DATE: 11/13/2023

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LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 10/15/23. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Two staff members were interviewed.

Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. Two client medication was reviewed. One client was interviewed.

No deficiencies cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted and technical assistance provided. A copy of this report was discussed and left with Gloria Callejas.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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